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Effective Auditing of Physicians' Notes

Gain an understanding of audit factors that are most important, and what to do if the audit yields a bad result.Auditing provider clinical records (i.e, the visit note) is a critical part of building a strong compliance program that defines what is needed in producing a high quality meaningful note. The days of creating three-page clinical notes with useless information are gone. The note must be the focus and deliver the critical information others need to care for the patient. The clinical record needs to mirror the level of coding within the requirements of the American Medical Association Evaluation and Management coding requirements. Three to five-page notes are no longer needed. Learn to effectively audit the provider clinical note and stay in compliance.


Runtime: 88 minutes
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Why Lorman?

Over 30 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

Understanding the Strong Arm of the Law

  • Why We Monitor and Audit – and What’s the Difference Between the Two?
  • The Risks Associated With Not Having an Effective Compliance Program
  • Recent Governmental Audit Pursuits
  • Repercussions of Inadequate Auditing and Monitoring

Compliance Auditing

  • Effective Ways of Structuring an Audit
  • Pinpointing Documentation Issues
  • Documenting Findings
  • Physician Documentation Short Cuts
  • Auditing Electronic Medical Records - The Dangers of Cutting and Pasting

Addressing and Reporting Findings

  • Assessing the Data for Reporting Purposes
  • When do you need to call the lawyer?
  • What Do We Do Next?
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Why Lorman?

Over 30 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

OnDemand Webinar

This course was last revised on May 3, 2017.

Call 1-866-352-9540 for further credit information.

  • AHIMA 1.5 including External Forces 1.5
     
  • This program has been approved for 1.5 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.
     

Audio & Reference Manual

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Why Lorman?

Over 30 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Nancy L. Freeman, RHIA, CHC, MBA, MHA

Nancy L. Freeman, RHIA, CHC, MBA, MHA

FTI Consulting

  • Managing director at FTI Consulting based in Atlanta, GA with more than 30 years of experience working on complex coding, billing, and health care compliance issues
  • Focuses on addressing complex coding and billing concerns in a variety of provider settings; clients include large and small hospitals and health systems, academic medical centers, physician groups
  • Experience includes not only working with providers on general compliance reviews, but also working with legal counsel to address complicated coding/billing matters and investigations relating to qui tam, voluntary disclosures, PATH audits, RADV audits, and the requirements of corporate integrity agreements
  • B.S. degree in medical record administration, Medical College of Georgia; Master's degrees in business and health administration, Georgia State University
  • Can be contacted at 678-429-9704 or [email protected]
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Product ID: 400285
Published 2017
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